Cognitive Rehab Lit at Ion in Schizophrenia

8/6/2019 Cognitive Rehab Lit at Ion in Schizophrenia

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by Irene M. Hurford, MD,Solomon Kalkstein, PhD, and

Matthew O. Hurford, MD

Patients with schizophrenia

have profound and disabling

cognitive deficits. More so

than positive or negative symptoms,

cognitive deficits impair daily func-

tioning and contribute most to chron-

ic disability and unemployment.1,2

Unlike the psychotic symptoms,

these deficits do not improve during

periods of remission and change

only minimally with antipsychoticmedications.3,4 Given the enormous

impact that cognitive dysfunction

has on the daily lives of persons with

schizophrenia, researchers and clini-

cians have been working for more

than 2 decades on strategies to im-

prove cognition in this population.

In this article, we summarize gen-

eral concepts in cognitive rehabilita-

tion in schizophrenia. Our goal is to

provide a basic framework for clini-

cians who are planning to initiate a

cognitive remediation (CR) program

for their patients.

Cognitive deficits inschizophreniaIn persons with schizophrenia, cog-

nitive impairments are detectable as

early as age 6 or 7 years, or the earli-

est age at which children receive any

formal psychological tests.5-8 The un-

derlying pathology is almost certain-

ly present in some form at birth. By

first grade, children in whom schizo-

phrenia develops are already per-

forming at nearly a full grade equiva-

lent below their peers.5 There appears

to be a period of further cognitive de-

cline (or rather, failure to make age-

appropriate gains) between the ages

of 12 and 17several years before

the first psychotic episode.5,6,9 After

the first episode, and the patient has

stabilized clinically, the cognitive

deficits remain fairly stable.10-12 At

that point, scores of global cognition

range from between 1 and 2 standard

deviations below those of healthy

cohorts.13,14

While all domains of cognition

are affected in schizophrenia, there

are selective areas of increased im-pairmentparticularly verbal and

visuospatial memory, attention, ex-

ecutive function, and speed of pro-

cessing (Table 1).15-20 Verbal memory

impairments are the most robust and

the most profound.10,14-16,18 Impair-

ments in cognition are not related to

illness state and are present and sta-

ble even during periods of positive-

symptom remission. In fact, positive

symptoms and cognitive deficits are

only negligibly correlated.21 How-

ever, negative and disorganization

symptoms show modest correlations

with cognition.21,22

Functional consequences ofcognitive deficitsRelative to the positive, negative,

and disorganization symptom do-

mains, cognition is the strongest pre-

dictor of functional outcome.1,2 Cog-

nitive deficits in schizophrenia have

been shown to interfere with various

aspects of daily functioning, includ-

ing employment, independent living,

and quality of life.23-26 In 2 literature

reviews, Green and colleagues1,2

demonstrated that 4 specific neuro-

cognitive domains were significantly

associated with functional outcomes:

executive functioning, immediate

verbal memory, secondary verbal

memory, and vigilance. Community

activity (eg, working, going to

school) was predicted by measures

of executive functioning and second-

ary verbal memory. Social problem-

solving skills were associated with

levels of secondary verbal memory,

vigilance and, to a lesser extent, ex-

ecutive functioning. Psychosocial

skill acquisition was most frequentlylinked with immediate and second-

ary verbal memory.2

Definition of cognitiverehabilitationThere are 2 main techniques in cog-

nitive rehabilitation: remediation

and compensatory approaches. CR is

designed to stimulate new learning,

or relearning, of cognitive tasks, and

thus, to improve domains of deficit.

Compensatory approaches seek to

make improvements in the patients

functioning by avoiding areas of im-

pairment and recruiting other intact

cognitive domains or by creating asupportive external environment.27

Compensatory techniquesCompensatory approaches aim not

only to improve cognitive function-

ing by reducing errors in the learning

process but also to minimize impedi-

ments to activities of daily living and

to create a supportive home environ-

ment. Errorless learning (EL) and

cognitive adaptation training (CAT)

are 2 compensatory approaches that

have yielded successful outcomes

when they are used in patients with

schizophrenia.

EL is guided by the theory that

certain neurologically impairedgroups, including persons with

schizophrenia, have difficulty in

learning when their mistakes are cor-

rected in an effort to guide future be-

havior.28 EL aims to eliminate any

errors when new tasks are being

learned. This approach reduces each

new task to be learned into small

component parts that are then over-

learned through imitative learning

and repetitive practice of perfect task

execution. By doing so, EL relies on

implicit memory processes; this pro-

vides an advantage for patients

whose explicit memory abilities are

compromised. Implicit learning re-

fers to learning that occurs uncon-

sciously and that is often procedural

(eg, riding a bike). In contrast, ex-

plicit learning is conscious and is

often more information-based.

Compensatory strategies have al-

so been applied to the schizophrenia

patients home environment. CAT

introduces environmental adapta-

tions that are suited specifically to

the executive impairments common

among schizophrenia patients. Itsaim is to reduce the cognitive bur-

dens, functional requirements, and

overall stress of everyday living in

each patients personal space.29

During home visits, CAT thera-

pists check for safety hazards and

ensure that necessary supplies are

available. The therapists may also

assist in modifying and reorganizing

the home in a manner customized to

the individual patients needs. For

example, in the bedroom, clothing

drawers are labeled and colored bins

are used for the sorting of dirty and

clean clothes. In the bathroom,

grooming supplies are moved to bemore easily accessible and pill con-

tainers are introduced to organize

medications. In addition, patients

can be trained to use watches or other

devices with alarms to cue them-

selves to take medications and com-

plete other tasks.30

Cognitive remediationtechniquesWhile early CR programs used paper

and pencil tasks, most are now com-

puterized. Some remediation pro-

grams use a mix of general educa-

tional software, but many train

participants with specialized com-

puter software designed to improvecognition (Table 2).31 Often the soft-

ware is adapted from computer exer-

cises for remediating age-related

cognitive decline, brain injuries, or

learning disabilities in children.32,33

Currently, most programs use a form

of drill and practice training, which

refers to the use of hundreds of trials

of the same exercise to push intrin-

sic learning systems that are hypoth-

esized to be intact in schizophrenia.34

Because of its repetitive nature, drill

Strategies to Improve Cognition

Cognitive Rehabilitation in Schizophrenia

SCHIZOPHRENIAPSYCHIATRIC TIMES 43

www.psychiatric t imes.com

MARCH 2011

(Please see Cognitive Rehabilitation, page 44)

What is already known about cognitive

impairment in schizophrenia?

Cognitive impairment in schizophrenia is profound, is enduring, and significantly

negatively affects functional outcome and the ability to live and work

independently.

What new information does this article add?

This article reviews methods to rehabilitate cognition in schizophrenia and suggests

strategies for instituting a cognitive remediation (CR) program.

What are the implications for psychiatric practice?

For clinicians interested in CR for their patients, this article describes the basic

structure of such a program and gives references for relevant and useful resources.


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tional rehabilitation alone.

McGurk and colleagues40 also

pair CR with a supported employ-

ment program. Their Thinking Skills

for Work program has 4 components:

Cognitive assessment and job loss

analysis that identifies the role of

cognitive deficits in past job per-

formance and motivates patient

participation in the cognitive

training program

Computer-based cognitive train-

ing sessions

Discussion of cognitive gains

made following the completion of

training and future-oriented plan-

ning with the patient and employ-

ment specialist

Ongoing follow-up between the

employment specialist and the pa-

tient to develop additional com-

pensatory strategies to manage

cognitive deficits interfering withjob performance

Effectiveness of cognitiverehabilitationCompensatory strategies. Kern and

colleagues28 explored the effective-

ness of EL in community settings.

The results of their work show im-

provement in the learning of simple

entry-level job tasks, such as index

card filing and toilet tank assembly.

Another community-based study

used EL to train participants with

schizophrenia or schizoaffective dis-

order in entry-level tasks at a thrift-

type clothing store and found signifi-

cantly better work quality when

compared with participants trained

using conventional methods.41

Randomized studies have demon-

strated that CAT results in greater

adaptive function, better quality of

life, and fewer positive symptoms

than other forms of psychosocial

treatment.42 CAT has also been asso-

ciated with a reduced incidence of

re-hospitalization and with improved

levels of motivation and community

bottom-up improvement in higher-

order cognitive domains.

To date, there has been no head-

to-head comparison of bottom-up

and top-down approaches. While al-

most all CR programs use at least

some repetitive practice of cogni-

tive exercises to target domains of

deficit, many also include other

unique components beyond drill and

practice.

Cognitive enhancement therapy

(CET), developed by Hogarty and

colleagues,38 includes small-group

sessions that emphasize social cogni-

tion. CET improves neurocognition

and shows trends toward improving

social cognition. In a randomized

trial using CET, improvements in

neurocognition and some aspects of

social cognition independently pre-

dicted improvements in functional

outcome.Neurocognitive enhancement

therapy (NET), a program that was

developed by Bell and colleagues,39

pairs a drill and practice style com-

puterized CR with vocational reha-

bilitation programs. His team has

demonstrated that the combination

of the two improves work outcomes

significantly compared with voca-

be generalized to real-world activi-

ties, such as independent living and

employment. In a 2007 meta-analy-

sis, McGurk and colleagues35 found

that the combination of drill and

practice training and strategy coach-

ing was more effective than either

system alone.

Most CR programs aim to im-

prove the cognitive domains usually

associated with deficits in schizo-

phreniafor instance verbal and vi-

sual working memory, executive

function, attention, and processing

speed. This is a top-down approach

in which the target of training is a

higher-order cognitive process.

Fisher and colleagues36 adopted a

computerized remediation program

called Posit Science. This program

focuses on early auditory and visual

sensory processes, such as tone and

phoneme discrimination, as well ashigher-order cognitive processes,

such as verbal memory. Vinogradov

believes that focusing on early sen-

sory processing in schizophrenia is

important because previous research

findings indicate that there are early

sensory processing deficits in schizo-

phrenia.37 By improving these early

sensory processes, there will be a

and practice runs the risk of boring

participants. This is mitigated by the

use of computer gamelike motiva-

tions and rewards, such as colors,

noises, increasing scores, and en-

couraging words.

A few CR programs focus primar-

ily on a strategy-coaching approach,

in which the therapist and a small

group of patients discuss methods

and strategies to improve cognition

and to use cognitive-training exer-

cises. Strategy-coaching methods do

not usually focus on the repetition of

hundreds of trials per exercise; rath-

er, they place more emphasis on de-

veloping and maintaining motivation

in the participants.31

The Neuropsychological Educa-

tional Approach to Rehabilitation(NEAR) method uses a strategy-

coaching approach.31 This approach

also includes small-group sessions

(bridging groups) that occur after the

computerized CR portion of the

training. Participants discuss strate-

gies that they learned while practic-

ing the tasks as well as how the skills

they are learning in the sessions can

SCHIZOPHRENIA

Cognitive RehabilitationContinued from page 43

44 PSYCHIATRIC TIMESwww.psychiatric t imes.com

MARCH 2011

Remediation programs and resources

Research program Program, Web site, or software package Additional elements

Cognitive enhancement therapy38,48 A version of PSS CogReHab software Social cognition remediation in small groups

http://cognitiveenhancementtherapy.com

Neurocognitive enhancement therapy39,54,57 Modified version of PSS CogReHab software Vocational rehabilitation

http://www.neuroscience.cnter.com/PSS/psscr.html

Thinking Skills for Work40,52,58,59 CogPack software Vocational rehabilitation, supported employment

http://www.Cogpack.com

Posit Science32,36 Posit Science

http://www.positscience.com

Neuropsychological Educational Approach Cognitive Remediation for Bridging groups

to Rehabilitation31,60-63 Psychological Disorders: Therapist Guide

Table 2

Definition of cognitive domains affected in schizophrenia

Cognitive measure Definition

Working memory Temporary online storage of information and mental manipulation of

information

Attention (sustained focused attention or vigilance) Ability to maintain a consistent behavioral response throughout a

continuous or repetitive activity

Speed of processing More basic cognitive processes involving speed of performance,

whether perceptual or motor

Verbal learning and memory The ability to acquire and retain verbal information, such as

verbal instructions

Visuospatial learning and memory The ability to acquire and retain visual information, such as

figures and maps

Table 1


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ments in global cognition as a result

of CR have been demonstrated to

mediate improvements in measures

of functional outcome.51 However, it

appears that for CR to best translate

into improvements in functional out-

come, it should be paired with some

other psychosocial rehabilitation

program, such as vocational reha-

bilitation or social skills training.

functioning.43 While EL and CAT use

different compensatory approaches,

both appear to be beneficial in the

treatment of cognitive deficits in

schizophrenia.

Cognitive remediation. CR has

been demonstrated to improve over-

all (global) cognition as well as spe-

cific domains, including attention,

executive function, working memo-

ry, verbal learning and memory, pro-

cessing speed, and affect recogni-

tion.38-40,44-47 The effect sizes for

improvements in cognitive domains

generally fall into the small to mod-

erate range (about 0.3 to 0.6).35,45 Ef-

fect sizes for improvements in global

cognition tend to be in the moderate

range as well.35,45 (Of note, moderate

effect sizes are generally considered

meaningful in the social sciences,

but the improvements in cognition

after CR merely attenuate the degreeof deficit, which still remains large

compared with that in control sub-

jects.) These improvements in cogni-

tion often persist after CR has end-

ed.35 In their study, Hogarty and

colleagues48 tested participants 12

months after the completion of CET

and reported that improvements in

processing speed, cognitive style, so-

cial cognition, and social adjustment

persisted.

Furthermore, results from a ran-

domized controlled trial using MRI

data indicate that 2 years of CET

therapy resulted in decreased gray

matter loss in several areas of the

cortex and increased gray matter in

the amygdala in participants with

early-onset schizophrenia.49 Howev-

er, not all studies have found that CR

improved cognitive performance.

Dickinson and colleagues50 conduct-

ed a randomized controlled trial and

reported that while CR improved

cognitive domains and global cogni-

tion when tested on the same exer-

cises included in the remediation

program, neither global cognition

nor any cognitive domain improved

when tested with a standardized neu-

rocognitive battery. This study illus-

trates the potential danger of training

to the test or of testing subjects usingcognitive batteries too similar to the

tasks practiced in the CR program.

Effect on functional outcomeand quality of lifeThe ultimate goal of all the programs

discussed is the successful transfer

of gains made in CR to improve-

ments in functional outcome and

quality of life. Multiple studies have

shown improvements in measures of

functional capacity or functional out-

come after CR. In addition, improve-

SCHIZOPHRENIA

worked, and higher wages, both in

noncompetitive and competitive em-

ployment.40,44,50-54 Not all studies have

found improvements in functional

outcome with CR, however.50,55

ConclusionSchizophrenia is associated with se-

vere cognitive deficits that interfere

Findings from the meta-analysis by

McGurk and colleagues35 showed

that CR in conjunction with other

psychiatric rehabilitation programs

improved psychosocial functioning

measures more than just CR alone.

CR has been shown to enhance

the effectiveness of vocational reha-

bilitation and to lead to higher em-

ployment rates, more hours or weeks

MARCH 2011 45PSYCHIATRIC TIMESwww.psychiatrictimes.com

(Please see Cognitive Rehabilitation, page 46)

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significantly with daily functioning

and quality of life. Compensatory

programs can recruit intact cogni-

tive skills or marshal environmental

supports to improve functioning.

CR lessens cognitive deficits, and

when paired with other rehabilita-

tion programs, can lead to lasting

improvements in cognition and daily

functioning.

Keep in mind that persons with

schizophrenia often have poor in-

sight into their cognitive deficits,

which potentially limits the appeal of

time-consuming remediation pro-

grams.56 Clinicians may need to

frame the goals of CR in very con-

crete terms to encourage participa-

tion in the program.

Dr Irene M. Hurford is assistant professor in

the department of psychiatry at the University

of Pennsylvania in Philadelphia and psychia-

trist in the department of behavioral health

at the Philadelphia VA Medical Center. Dr

Kalkstein is a psychologist in the department

of behavioral health at the Philadelphia VA

Medical Center. Dr Matthew O. Hurford is as-

sistant professor in the department of psy-

chiatry at the University of Pennsylvania. The

authors report no conflicts of interest con-

cerning the subject matter of this article.

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Cognitive RehabilitationContinued from page 45

SCHIZOPHRENIA46 PSYCHIATRIC TIMES


MARCH 2011

Recommended inclusion criteria

for cognitive remediation

Ages 13 through 65 years

Premorbid IQ over 70

Reading level equal to or greater than 4th grade

No active substance or alcohol abuse

No traumatic head injury within the past 3 years

Psychiatrically stable enough to attend sessions to completion

Table 3

Proposed flowchart forinstituting cognitive remediation

Figure

Recruit participants

Initial assessment

meeting:

neurocognitive

testing

Second meeting:

discuss test findings,set goals

Final cognitive

testing

Wrap-up session: review

cognitive gains, initial goals,

and achievements during

the program

Computerized cognitive

remediation for

45 minutes

2 or 3 times a week

Start remediation

or compensation

program:

4- to 6-month program

Bridging group with

focus on transfer of skills

to vocational training for

15 minutes 2 or 3 times a week


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SCHIZOPHRENIAMARCH 2011 47PSYCHIATRIC TIMES


In their guide to cognitive remediation (CR), Medalia and associates31 recom-

mend that candidates for this program meet the criteria listed in Table 3. The

Figure provides a proposed flowchart for CR programs. The details of each

step are described below.

STEP 1: ASSESS BASELINE COGNITION

Neurocognitive assessment is an important part of CR programs. Some com-

puterized remediation programs may include cognitive testing at baseline

and at the end of training. If not, neurocognitive assessment must be admin-

istered and interpreted by a trained neuropsychologist or psychometrician.

STEP 2: SET GOALS

After the test results have been returned, the clinician meets with the participant to discuss the findings, in

particular, to highlight areas of cognitive strength and weakness, and to help the participant identify reason-

able and achievable goals for the CR program. Goals do not need to be cognitive (eg, improving my atten-

tion) but are ideally related to potential cognitive change (eg, being able to understand my doctors medi-

cation instructions, remembering what my boss wants me to do for the day).

STEP 3: START CR PROGRAMCR can now commence. It is more cost- and time-effective to conduct CR in groups of about 3 to 5 partici-

pants. It also creates a manageable group size for bridging groups, or for social cognition or vocational train-

ing groups. However, CR can be done individually as well. CR programs run anywhere from 3 months to 2

years, but many average about 4 to 6 months. Frequent sessionsat least twice a weekare crucial. In many

programs, groups meet 3 or 4 times a week. In others, groups meet weekly, and participants do many of the

remediation exercises at home.

STEP 4: INCLUDE ADDITIONAL PSYCHOSOCIAL PROGRAM OR BRIDGING GROUP

To obtain the greatest transfer of skills from CR to real-world functioning, CR is best paired with some form

of psychosocial rehabilitation program. This can be social skills training, supported employment, vocational

rehabilitation, or a bridging group (for more detail about bridging groups see Medalia et al31). Without the

inclusion of some type of additional psychosocial training, it is likely that the gains seen with CR will not

transfer to real-world functioning. This probably occurs because the improvements from CR run the risk of

being gains without context and therefore are difficult to maintain unless they are paired with some kind ofbridge to social or functional activities and outcomes.

STEP 5: FINAL COGNITIVE TESTING

This testing is a repeat of the baseline testing. It allows clinicians to assess the impact that CR has had on the

participants cognitive abilities. Again, if this testing is not included in the CR software, it is imperative that it

be administered and interpreted by a neuropsychologist or psychometrician.

STEP 6: WRAP-UP

Discuss the results of the final cognitive testing, review the participants initial goals and the progress made

toward them, and discuss future ambitions and how the gains made during cognitive training may help the

participant achieve those goals.

Guidelines for Developing a Cognitive Remediation Program for

Patients With Schizophrenia


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